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9.0 The Norplant system

9.1 Method

It is a long acting low dose, reversible, progestin-only method of contraception for women. The system contains 6 capsules each measuring 34 mm in length and 2.4 mm in outer diameter containing 36mg crystalline levonorgestrel. It is effective for up to 5 years after insertion.

9.2 Mechanism of action

The capsule releases approximately 85 g of LNG per 24 hours during the first 6-12 months of use, and 50 g/day by 9 months and, thereafter, 30 g/day for the remaining duration of use. There are three probable mechanisms of action :

suppresses LH surge necessary for ovulation. About 10% women ovulate during first 2 years of use and 50% by 5 years. But in the ovulatory cycles there is high incidence of ovulatory insufficiency

thickens cervical mucus and decreases the amount of mucus forming a barrier to sperm penetration

inhibits endometrial maturation and causes its atrophy thus preventing implantation

9.3 Advantages

rapidly reversible. Ovulatory cycles are restored within the first month after removal in most women

highly effective

continuous method without much effort or motivation by the user

not a coitus-related method

user effectiveness closely approximates the theoretical effectiveness

can be inserted 6 weeks post-partum in lactating women

no estrogenic side-effects

prevents iron deficiency anaemia

9.4 Disadvantages

weight gain

breast tenderness

disruption of menstrual cycles especially during first year of use

insertion and removal requires a surgical procedure by a trained personnel

higher initial cost as compared to OCPs and barrier methods

implant is visible under the skin and may be unacceptable to users

offers no protection against STI / HIV

9.5 Contraindications

breast-feeding women less than 6 weeks post-partum

current deep vein thrombosis/pulmonary embolism

history of stroke

current or past history of ischaemic heart disease

migraine with focal neurological deficit

unexplained vaginal bleeding not evaluated

current and past history of breast cancer

active hepatitis, liver tumors

patient on drugs likely to affect metabolism of LNG eg. - phenytoin, phenobarbitone, rifampicin etc.

9.6 Instructions for use

It is important to know when to insert a Norplant.

During menstrual cycle

any time it is certain that woman is not pregnant. If started within first 7 days of menstrual bleeding no back-up methods is required.

Post-partum

breast-feeding mothers as early as 6 weeks post-partum

non breast-feeding mothers immediately or any time she desires within 6 weeks post-partum

After spontaneous or induced abortion

immediately or within first 7 days after first or second trimester abortion

When stopping other method

immediately


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